Prevalence of rabies in China is under-reported and veterinarians urge people planning to move to the country to get vaccinated first.

The expatriate American had been living in Shanghai with his family when he developed a bout of hiccups that just wouldn’t stop. It got so bad he went to see a doctor. Within weeks he was dead.

What he, his family and the doctor hadn’t realised: The hiccups were a neurological reaction to a rabies infection.

This cause of this tragedy wasn’t a bite from a snarling mad dog, it was traced to a puppy the family had bought a few months earlier at a pet store. The dog seemed healthy, hadn’t bitten anyone, but it had licked the face of the father, as puppies do, and transmitted the virus through its saliva. Luckily for the mother and child in the family, they had been vaccinated. The father hadn’t.

Rabies, which kills through acute brain inflammation, has been brought under control in many countries through vaccination and strict pet immigration rules. That’s not the case in China, India and in many areas of the developing world where it still kills one person every ten minutes, according to the World Health Organisation (WHO). Most victims are children.

“You shouldn’t be afraid of going to China and other rabies endemic countries,” said Mary Peng, founder of the International Center for Veterinary Services in Beijing. “But when you do, you should first get a vaccination.”

The company that employed the American in Shanghai, now has a worldwide policy stipulating all employees moving to countries with rabies must first get vaccinated, Peng said. Such policies are too rare, she said, adding she was not directly involved in this specific case and therefore unable to give further details.

Peng said she gets regular calls from expatriates and locals about rabies, but many foreigners do not realise the relatively high risk of getting infected in the region.

“The countries most of them are from are already very well rabies controlled, like the US, or rabies free, like the UK. They don’t have rabies education or the understanding they now are in a rabies endemic country,” she said.

There is also a misconception that dogs with rabies are aggressive with drooling jaws and yellow crazy eyes, a state known as “furious form” by veterinarians and depicted in the Stephen King novel “Cujo” in which a rabid St Bernard goes on a rampage in a small village. In fact, a puppy that just wants to play could be rabid and transmit the virus.

“I’ve never met a puppy that doesn’t lick me all over my face. That’s what puppies do. And when they lick your face, lips, nostrils, eyes, these are entryways into your body via salvia,” Peng said.

Dogs are the source of 99 percent of all rabies transmissions to humans, according to the WHO. In the Americas, bats are the source of most rabies infection in humans.

Every year about 60,000 people die from rabies, most of them in Asia and Africa, according to WHO. India accounts for more than a third of these cases, while in China about 2,000 people die from rabies every year. Most experts, including the WHO, believe the actual number to be considerably higher due to under-reporting and negligence.

China’s dog population has increased dramatically in recent years as owning a dog became a middle-class status symbol. The Chinese government has registered a total of 80 million dogs, with 14 million in urban areas, according to the WHO. But the actual number is believed to be much higher as many owners don’t bother to register their pets.

Worryingly, few of these dogs have been vaccinated against rabies. Peng said that just 10 to 20 percent of all dogs in China are properly vaccinated. In the countryside the rate is lower than 3 percent.

This is far from the minimum effective vaccination coverage rate of at least 70 percent that is needed to create a barrier to rabies transmissions to humans.

The low vaccination rate in China reflects a general lack of knowledge about rabies, Peng said. But it’s also because dog owners can’t buy the vaccine through their regular veterinarians; it’s a government monopoly where only officially designated animal clinics can legally supply the vaccine.

The increased numbers of dogs combined with the government restrictions has created a massive black market for both human and animal vaccine (see separate article).

World Health Organization 2015 infographic on rabies

Kati Loeffler, veterinary advisor at the International Fund for Animal Welfare in Massachusetts, U.S., said that rabies is primarily a disease of marginalized people who are often missed in statistics, medical care and education.

Dogs often don’t get vaccinated because governments don’t invest in canine rabies prevention programs, while children and parents are often poorly informed about the importance of first-aid for bite wounds, Loeffler said.

“Finally, when a bite victim is transported to a medical facility, the medical staff are often either poorly trained in administration of the correct treatment, or they do not have the necessary medical supplies to provide adequate care,” she told Asia Times.

The U.S. Centers for Disease Control and Prevention also recommends that travelers and expatriates moving to China and India should be vaccinated against rabies, especially those involved in outdoor activities, such as camping or hiking, or working around animals. It stresses the need for children to be protected.

“Children are often at greatest risk from rabies. They are more likely to be bitten by dogs, and are also more likely to be severely exposed through multiple bites in high-risk sites on the body”, the CDC said on its website.

Although the number of people killed by rabies in China has fallen over the last decade, a new study by China’s Academy of Military Medical Sciences showed that the epidemic is spreading into previously rabies-free or low-incidence provinces in northern China.

Peng shared another story. Last year, a European family living in China adopted a puppy. It started to act strange and bit two of the family members. They took it to an animal hospital where it bit three more people. The dog died a week later and an autopsy revealed rabies. Luckily, all the people survived. The hospital staff were already vaccinated and when the dog bit the family members it didn’t break skin. They all had vaccination treatment, Peng said.